226 Case reports have also described the outcome of patients with severe AH treated with leukocytapharesis after failing to improve substantially on steroids.227, 228 These reports are promising, but recommendations regarding their appropriate use must await results CH5424802 cost of comparative studies of
outcomes in these patients. A proposed treatment algorithm for alcoholic hepatitis is shown in Fig. 1. Recommendations: 8. All patients with alcoholic hepatitis should be counseled to completely abstain from alcohol (Class I, level B). 9. All patients with alcoholic hepatitis or advanced ALD should be assessed for nutritional deficiencies (protein-calorie malnutrition), as well as vitamin and mineral deficiencies. Those with severe disease should be treated aggressively with enteral nutritional therapy (Class I, level B).
10. Patients with mild-moderate alcoholic hepatitis—defined as a Maddrey score of <32, without hepatic encephalopathy, and with improvement in serum bilirubin Selleckchem NVP-LDE225 or decline in the MDF during the first week of hospitalization—should be monitored closely, but will likely not require nor benefit from specific medical interventions other than nutritional support and abstinence (Class III, level A). 11. Patients with severe disease (MDF score of ≥32, with or without hepatic encephalopathy) and lacking contraindications to steroid use should be considered for a four week course of prednisolone (40 mg/day for 28 days, typically followed by discontinuation or a 2-week taper) (Class
I, level A). 12. Patients with severe disease (i.e., a MDF ≥ 32) could be considered for pentoxifylline therapy (400 mg orally 3 times daily for 4 weeks), especially 上海皓元医药股份有限公司 if there are contraindications to steroid therapy (Class I, level B). A proposed algorithm for the management of ALD is shown in Fig. 2. Protein calorie malnutrition is common in ALD, is associated with an increased rate of major complications of cirrhosis (infection, encephalopathy, and ascites), and indicates a poor prognosis.194 A total of 13 studies (seven randomized and six open-label studies) have examined the effect of oral or enteral nutritional supplementation in patients with alcoholic cirrhosis, with interventions that ranged from 3 days to 12 months (reviewed in Stickel et al.229). Most of these studies are limited by small sample sizes and short durations of therapy. In one study, enteral feeding for 3-4 weeks in 35 hospitalized, severely malnourished or decompensated patients with alcoholic cirrhosis seemed to improve survival (P < 0.065), hepatic encephalopathy, liver tests and Child-Pugh score, as compared with controls receiving a standard oral diet.197 In longer-term studies, equinitrogenous amounts of dietary branched chain amino acids (BCAA) were compared with casein supplements for 3-6 months in patients with chronic hepatic encephalopathy,230 and shown to improve encephalopathy, nitrogen balance and serum bilirubin compared with casein.